REVIEW

CURRENT
OPINION Advances in awareness monitoring technologies
Erica J. Stein a and David B. Glick b

Purpose of review
Initial studies suggested that the use of processed electroencephalogram technology could significantly
decrease the incidence of unintended intraoperative awareness events during general anesthesia.
Subsequent work has cast doubts on these findings. This review will examine the current state of awareness
monitoring.
Recent findings
Recently published randomized controlled trials examining the use of the bispectral index during general
anesthesia have not been able to show superiority over other forms of monitoring depth of anesthesia, such
as end-tidal anesthetic-agent concentration. Additionally, there is current interest in utilizing the
unprocessed electroencephalogram to ascertain depth of anesthesia and recent studies have demonstrated
its use in preventing postoperative delirium.
Summary
Although awareness monitors such as the bispectral index monitor may have benefit in patients in whom
volatile anesthetic agents must be minimized – such as in hemodynamically unstable patients, or patients
undergoing total intravenous anesthesia – these monitors do not appear to be useful for all patients.
Keywords
awareness, awareness monitor, bispectral index, electroencephalogram monitoring

INTRODUCTION intraoperative awareness, and found that light

During general anesthesia, anesthetic medications anesthesia could have been responsible for 87% of
are administered to control a patient’s somatic and the cases. Patients with a history of intraoperative
sympathetic responses to surgical stimulation and awareness, significant comorbidities [American
to provide amnesia and prevent intraoperative Society of Anesthesiologists’ (ASA) physical status
awareness. Unintended intraoperative awareness classification of 4 or 5], poor hemodynamic reserve,
occurs when a patient experiences and explicitly and/or patients with a history of substance abuse
recalls sensory perceptions during surgery [1]. The including patients with chronic pain on high-dose
incidence of intraoperative awareness for patients opioid regimens tend to be at high risk of awareness
having general surgery is 0.1–0.2%; however, [5]. With respect to type of anesthetic, any anes-
patients having cardiac surgery, cesarean section, thetic in which the ability to monitor anesthetic
or trauma surgery, are at highest risk for intraoper- depth is limited, such as total intravenous anesthe-
ative awareness, with the incidence increasing sia, wherein there is no end-tidal anesthetic
10-fold to almost 1% [2]. Although the risk of aware- gas concentration (ETAC), as well as the use of
ness is low, it can cause significant psychological prolonged neuromuscular blockade, in which the
trauma to the patient, resulting in post-traumatic clinical signs of light anesthesia may be masked,
stress disorder in as many as 70% of patients who
experience it [1].
Factors associated with an increased risk of a
Department of Anesthesiology, Ohio State University, Columbus, Ohio
intraoperative awareness can be grouped into three
and bDepartment of Anesthesia and Critical Care, University of Chicago,
categories: patient characteristics, procedure-related Chicago, Illinois, USA
issues, and anesthetic concerns [3]. With regard to Correspondence to Dr David B. Glick, MD, MBA, Professor, Department
both patient and procedural characteristics, the risk of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland
of intraoperative awareness appears to increase if Avenue, MC 4028, Chicago, IL 60637, USA. Tel: +1 773 702 5553;
doses of anesthetic agents are reduced, leading to a e-mail: [email protected]
lighter than intended level of anesthesia. Ghoneim Curr Opin Anesthesiol 2016, 29:711–716
et al. [4] reviewed a series of case reports of DOI:10.1097/ACO.0000000000000387

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Technology, education and safety

counseling in patients who had unintended

KEY POINTS intraoperative awareness [8]. All the attention to
 To date, there are no studies that show a definitive preventing unintended intraoperative awareness
benefit of using processed EEG monitors to prevent has led to the development of multiple brain elec-
unintended intraoperative awareness in all patients. trical activity monitors with the aim of preventing
intraoperative awareness.
 Measuring ETAC and maintaining it greater than 0.7
age-adjusted MAC can prevent awareness while being
most cost-conscious.
AWARNESS MONITORS
 Processed EEG monitors may be a useful adjunct, aside In the mid-1990s, depth of anesthesia monitors
from monitoring standard clinical signs of awareness, were introduced into the market with the hope that
in patients who are at high risk for intraoperative
they could decrease the risk of intraoperative aware-
awareness, hemodynamically unstable, or undergoing
a total intravenous anesthetic. ness. Several devices are still available, but none
have been shown to be 100% effective. These devices
 Having a better understanding of the impact of depth monitor brain electrical activity by assessing
of anesthesia on the unprocessed EEG is an area in electroencephalographic (EEG) activity from elec-
need of further research as monitoring the unprocessed
trodes placed on the forehead. They can be divided
EEG may have an impact on postoperative outcomes.
into those that process EEG activity and electromyo-
graphic (EMG) activity and those that acquire
evoked responses to auditory stimuli or auditory
have been shown to be associated with a higher evoked potentials (AEPs). Once the device amplifies
incidence of awareness [4]. and converts the analog EEG signal, proprietary
Therefore, assessing the depth of anesthesia and algorithms are applied to the frequency, amplitude,
reducing the risk of intraoperative awareness, latency, and/or phase relationship data derived
particularly, in high-risk populations, has been from the raw EEG or AEP to generate a quantitative
the subject of much research. During a general data point (usually a digit scaled from 0 to 100).
anesthetic, inhaled anesthetic gases are commonly The clinician can then use this data point to deter-
used to maintain general anesthesia, and the ETAC mine the effect of anesthetic drugs on the brain. For
of these gases is routinely measured. The minimum most processed EEG monitors, a value of 100 is
alveolar concentration (MAC) is the concentration associated with an awake state and a value of 0
of anesthesia required to prevent 50% of patients indicates an isoelectric EEG. Currently available
from moving in response to a noxious surgical EEG-based monitors include the bispectral index
stimulus. A study by Eger demonstrated that when (BIS; Covidien, Boulder, Colorado, USA), State and
ETAC is approximately 0.33 MAC, 50% of patients Response Entropy (SE and RE, GE Healthcare Tech-
would not respond to verbal commands, and nologies, Helsinki, Finland), Narcotrend Index
maintaining an age-adjusted ETAC 0.7 MAC will (Schiller AG, Baar, Switzerland), Patient State Index
prevent unintended intraoperative awareness [1,6]. (PSI; Hospira, Lake Forest, Illinois, USA), SNAPII
According to the ASA’s Practice Advisory for Intra- (Everest Biomedical Instruments, Chesterfield, Mis-
operative Awareness and Brain Function Monitor- souri, USA), and the Cerebral State Monitor (Dan-
ing, it is recommended that monitoring for clinical meter A/S, Odense, Denmark). The only evoked
signs (i.e., purposeful movement), and utilizing brain electrical activity monitor is the AAI 1.6
conventional monitoring systems (i.e., electrocar- (AEP Monitor/2, Danmeter A/S, Odense, Denmark).
diogram, blood pressure, ETAC), are valuable and
should be used to assess depth of anesthesia [7].
However, awareness has been reported in the Bispectral index and intraoperative
absence of tachycardia or hypertension [7]. awareness
In 2004, The Joint Commission issued a Sentinel The BIS is a dimensionless numerical scale that
Event Alert on ‘Preventing, and managing the measures brain activity and is derived from EEG
impact of anesthesia awareness’ in which recom- signal processing techniques that combine bispec-
mendations were made about premedication tral analysis, power spectral analysis, and time
with amnestic drugs, avoiding muscle paralysis domain analysis using a proprietary algorithm.
when feasible, timely maintenance of anesthesia The BIS index range (0–100) is meant to represent
equipment, and creating an awareness policy [8]. a continuum corresponding to the clinical state,
Additionally, this Sentinel Event Alert advised post- ranging from an isoelectric EEG (0) to a deep
operative follow-up for all patients having under- hypnotic state (40), general anesthesia (40–60),
gone a general anesthetic as well as advocated for light/moderate sedation (60–80), and awake

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 Advances in awareness monitoring technologies Stein and Glick

(80–100) [9]. The recommended range of the BIS Other applications of brain function monitors
index is between 40–60 for general anesthesia [1,2] Given the lack of conclusive evidence surrounding
and 55–70 during the last 15 min of surgery [10]. To the brain function monitors’ ability to prevent intra-
date, the BIS monitor has been the only brain operative awareness, practice patterns relating to
function monitor that has been studied in large their use vary substantially. The ASA’s Practice Advi-
randomized controlled trials (RCTs). Several of these sory for intraoperative awareness recommended
trials have compared outcomes with BIS-guided that the decision to use a brain function monitor
depth of anesthetic administration versus standard be made on a case-by-case basis with each patient’s
clinical practice without the use of the BIS monitor. anesthetic tailored to his/her comorbidities and the
Because the incidence of intraoperative awareness is procedure performed [7]. When reviewing practice
low, an extremely large number of patients are patterns regarding BIS monitor use, Gelfand et al. [5]
needed to achieve the statistical power necessary published a retrospective review of 55 000 patients
to determine the efficacy of the BIS for preventing undergoing general anesthesia and found that
intraoperative awareness. Myles et al. [2] published factors associated with BIS use were either patient-
the B-Aware trial in which adult patients were specific or case-specific. Patient-specific factors
randomly allocated to BIS-guided anesthesia or rou- included increased age, greater ASA physical status,
tine care in double blind fashion; the multicenter and extremes of BMI (35 < BMI < 19.9); case-specific
trial demonstrated that BIS-guided anesthesia factors including TIVA, use of nitrous oxide, utiliz-
reduces the incidence of awareness in high-risk ation of long-acting neuromuscular blockade, use
adult surgical patients having general anesthesia of endotracheal tube compared with supraglottic
[2]. Zhang et al. [11] found that a BIS-guided anes- airway, emergency cases, and cardiac surgery were
thetic decreased the risk of awareness in patients significantly more likely to have the monitor used
undergoing a total intravenous anesthetic (TIVA), during the anesthetic [5]. Even though this study
and determined that the main reason for awareness reported patients undergoing cardiac surgery
in the setting of TIVA was light anesthesia. On the to have an increased use of the BIS monitor, the
other hand, the B-Unaware and BAG-RECALL trials American Society of Extracorporeal Technology’s
showed that alarms to prevent light anesthesia standards and guidelines for perfusion practice do
based on the BIS (alert if 60 < BIS < 40) were not address the use of brain monitors to assess the
not superior to alarms based on the ETAC (alert if level of anesthetic depth [15].
1.3 MAC < ETAC < 0.7 MAC) in preventing aware- Another way brain monitors can be used is to
ness in high-risk patients [1,12]. More recently, study whether anesthetic depth is a predictor
Mashour et al. [13] published the largest RCT, which of anesthetic outcomes. Studies have found an
demonstrated that BIS is superior to clinical signs of association between intraoperative hypotension,
awareness, but not to ETAC maintained at greater low BIS values (<45), and low volatile anesthetic
than 0.5 age-adjusted MAC, in preventing explicit concentrations and increased postoperative
recall in patients having general anesthesia. In 2014, mortality; however, the statistical strength of these
a Cochrane review evaluating the effectiveness of associations is variable [16–18]. In 2012, Sessler et al.
BIS monitoring in preventing intraoperative aware- [19] published a study describing the ‘triple low’ –
ness concluded that BIS-guided anesthesia can intraoperative mean arterial pressure (MAP) less
reduce the risk of awareness in high-risk patients than 75 mmHg, BIS < 45, and MAC < 0.8 – being
compared with using clinical signs alone [14]. The associated with an increased risk of perioperative
review also stated that, ‘BIS-guided and ETAC- mortality, particularly if the ‘triple low’ lasted for
guided anesthesia may be equivalent in protection more than 15 min. In an effort to replicate this
&&
against intraoperative recall but the evidence for finding, Willingham et al. [20 ] performed a retro-
this remains inconclusive,’ as a large equivalence spective observational study (n ¼ 13 918) of patients
trial is necessary [14]. In summary, review of from three clinical trials (B-Unaware, BAG-RECALL,
the current literature suggests that the BIS index and the Michigan Awareness Control Study) in
is useful in providing information on depth of which the patients were propensity matched to
anesthesia during TIVA and may decrease awareness controls for comorbidities and demographic charac-
in this group of patients. On the other hand, BIS teristics, and found that patients with greater than
monitoring is not superior (and may, in fact, be 15 nonconsecutive minutes of the triple low were at
inferior) in preventing intraoperative awareness a significantly increased risk of 30-day and 90-day
compared with maintaining an ETAC greater than mortality (hazard ratio 1.09); with an approximately
0.7 age-adjusted MAC if using an inhaled anesthetic 10% increase in mortality for every 15 cumulative
&&
agent for maintenance of general anesthesia. minutes in the triple low state [20 ]. Another study

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Technology, education and safety

examined cumulative minutes of EEG suppression from the BIS-guided group, then the cost of that
in patients enrolled in the B-Unaware and BAG- anesthetic is $9.64/h, which demonstrates that the
REGALL trials. This observational study demon- overall increase in the cost is entirely attributable to
strated that EEG suppression was associated with the cost of the monitor [24,25]. Limitations to this
increasing anesthetic administration and patient study include the small number of patients enrolled
comorbidities, but it did not find an association as well as the use of a protocol for the administration
between >5 min of EEG suppression and postoper- of specific medications in the TIVA group (i.e.,
ative mortality [21]. However, EEG suppression and no benzodiazepines, narcotics), in addition to com-
concomitant hypotension (MAP < 55 mmHg) were paring the use of TIVA versus nonprotocolized
strongly associated with mortality; because this is an inhalational anesthesia.
observational study, it is unclear as to the causal
relationship as both EEG suppression and hypoten-
sion could be indicators of a patient’s poor pre- Unprocessed electroencephalographic
operative status [21]. These studies demonstrate monitoring
that further research is needed to assess the effect Given the recent research indicating that processed
of deep hypnotic time on postoperative outcomes. EEG monitoring (BIS) is not superior to monitoring
based on ETAC in preventing intraoperative
awareness, there has been a resurgence of interest
Cost implications of awareness monitoring in unprocessed EEG monitoring. Because the EEG
According to a recent Cochrane review, BIS-guided provides a direct measure of cerebral activity, anes-
anesthesia can significantly reduce recovery times thesiologists can be taught to recognize patterns
and use of medications [14]. This review of the associated with the awake state, maintenance of
literature found that the length of postanesthesia anesthesia period, and emergence. When a patient
care unit (PACU) stay was reduced by 6.75 min in is awake, the EEG activity shows prominent alpha
patients having BIS-guided anesthesia; however, activity (10 Hz). During maintenance of anesthesia,
there was no effect on time to home readiness. four phases can occur: phase 1, during this light
Additionally, this Cochrane review documented a stage of general anesthesia, there is a decrease in beta
significant reduction in both propofol consumption activity (13–30 Hz) and an increase in both alpha
(overall decrease 1.32 mg/kg/h) as well as volatile (8–12 Hz) and delta (0–4 Hz) activity; phase 2, the
anesthetic use (decrease of 0.65 MAC equivalents) in intermediate stage resembles phase 1, but is charac-
patients having a BIS-guided anesthetic [14]. How- terized by ‘anteriorization’ in which there is an
ever, there is limited data on the cost of drug usage increase in alpha and delta activity in the anterior
versus the cost of the BIS electrode sensor, which is a EEG leads relative to the posterior leads; phase 3,
single use strip, as well as the initial cost and main- the EEG is marked with periods of flattening
tenance of the BIS monitor. In a study by Paventi interspersed with periods of alpha and beta activity,
et al. [22], patients undergoing anesthesia with BIS also known as burst suppression; phase 4, the EEG is
monitoring had a lower total drug cost compared completely flat or isoelectric [26]. Surgery is gener-
with patients without BIS monitoring (0.70 versus ally performed in phases 2 and 3 during the main-
0.98 EUR/min/70 kg patient with sevoflurane), tenance of anesthesia. Emergence is reflected in the
while the cost of BIS monitoring was 14.01 EUR/ EEG as the patterns proceed in reverse order from
patient. In contrast, a more recent review by Rine- phase 2 or 3 to an active EEG, characteristic of the
hardt and Sivarajan [23] in 2012 demonstrated that awake-state. Recent studies utilizing the unpro-
BIS monitoring during inhalational anesthesia cessed EEG aspect of the BIS suggest that increases
adds to the cost of a general anesthetic, without in the suppression ratio may be associated with an
&&
providing any significant benefit. Most recently, in a increased risk of postoperative delirium [27,28 ].
relatively small (N ¼ 30) randomized double-blind Utilizing the unprocessed EEG to measure depth
trial of women undergoing rhytidoplasty with either of anesthesia and postoperative outcomes is still a
propofol/ketamine TIVA using a BIS-monitored field in which further research needs to be done.
protocol or an inhalational anesthetic without
BIS-monitoring, a statistically significant reduction
in emergence time and time to meet discharge Limitations
criteria in the BIS-monitored group was demon- When using either the BIS or unprocessed EEG, the
strated [24]. Additionally, the cost of anesthesia anesthesiologists should be aware of several limita-
administration was similar in the BIS monitored tions. Because the BIS algorithm was developed using
group ($10.37/h) and inhalational anesthetic group healthy volunteers with normal EEG patterns, any
($9.87/h); if the cost of the BIS monitor is subtracted pre-existing neurologic disorder that exhibits

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 Advances in awareness monitoring technologies Stein and Glick

abnormal EEG waveforms can affect the BIS. Patients Conflicts of interest
with Alzheimer’s or vascular dementia, show an There are no conflicts of interest.
increase in the slow wave activity of the EEG, associ-
ated with a lower mean awake BIS [29]. Additionally,
patients with cerebral vascular disease may have REFERENCES AND RECOMMENDED
cerebral ischemia leading to cortical inactivation READING
Papers of particular interest, published within the annual period of review, have
leading to EEG slowing or a decrease in the BIS been highlighted as:
[30]. Second, the affect of muscle relaxants and & of special interest
&& of outstanding interest
muscle activity on the EEG is controversial. In the
nonparalyzed patient, scalp electrical activity might 1. Avidan MS, Jacobsohn E, Glick D, et al. Prevention of intraoperative aware-
ness in a high-risk surgical population. N Engl J Med 2011; 365:591–600.
contaminate the EEG, thereby influencing the proc- 2. Myles PS, McNeil J, Forbes A, Chan MTV. Bispectral index monitoring to
essed EEG, with the BIS algorithm being unable to prevent awareness during anesthesia: the B-Aware randomized controlled
trial. Lancet 2004; 363:1757–1763.
distinguish EMG signals from higher frequency 3. Kelley SD. Intraoperative awareness. In: Vacanti C, Segal S, Sikka P, Urman
EEG activity, in some instances [31]. Aside from R, editors. Essential clinical anesthesia. Cambridge: Cambridge University
Press; 2011. pp. 209–212.
neuromuscular blocking agents, each class of anes- 4. Ghoneim MM, Block RI, Haffarnan M, Mathews MJ. Awareness during
thetic drugs has a different EEG response [31]. There- anesthesia: risk factors, causes and sequelae: a review of reported cases
in the literature. Anesth Analg 2009; 108:527–535.
fore, various combinations of medications can affect 5. Gelfand ME, Gabriel RA, Gimlich R, et al. Practice patterns in the intrao-
both the EEG and the processed EEG. For example, perative use of bispectral index monitoring. J Clin Monit Comput 2016 [Epub
ahead of print]. doi: 10.1007/s10877-016-9845-5.
high doses of opioids can cause a paradoxical increase 6. Eger II EI. Age, minimum alveolar anesthetic concentration, and minimum
in the processed EEG, while low doses of ketamine alveolar anesthetic concentration-awake. Anesth Analg 2001; 93:947–
953.
can result in increased high frequency EEG activity, 7. American Society of Anesthesiologists. Practice advisory for intraoperative
leading to an overestimated BIS index [30]. Finally, awareness and brain function monitoring: a report by the American Society of
Anesthesiologists task force on intraoperative awareness. Anesthesiology
hypothermia causes EEG suppression. Several studies 2006; 104:847–864.
have reported that hypothermia reduces the BIS by 8. The Joint Commission. Preventing, and managing the impact of, anesthesia
awareness. Sentinel Event Alert 2004; 1–3.
approximately one BIS unit per degree Celsius [31]. 9. BIS Monitoring Technology. http://www.medtronic.com/content/dam/covi
Other factors such as electrocautery, cardiac atrial dien/library/us/en/legacyimport/patientmonitoringrecovery/patient-monitor
ing/6/bis-monitoring-technology-enabling-safety-quality-or-brochure.pdf
pacing, and vibrations from forced air warmers have [Accessed 4 July 2016].
been shown to result in frequencies that can interfere 10. Gan TJ, Glass PS, Windsor A, et al. Bispectral index monitoring allows faster
emergence and improved recovery from propofol, alfentanil and nitrous oxide
with the BIS leading to a false value [32]. anesthesia. Anesthesiology 1997; 87:808–815.
11. Zhang C, Xu L, Ma Y, et al. Bispectral index monitoring prevent awareness
during total intravenous anesthesia: a prospective, randomized, double-
CONCLUSION blinded, multicenter controlled trial. Chin Med J 2011; 124:3664–3669.
12. Avidan MS, Zhang L, Burnside BA, et al. Anesthesia awareness and the
Measuring depth of anesthesia and preventing unin- bispectral index. N Engl J Med 2008; 358:1097–1108.
13. Mashour GA, Shanks A, Tremper KK, et al. Prevention of intraoperative
tended intraoperative awareness remains a field that awareness with explicit recall in an unselected surgical population: a
requires further investigation. It appears that the randomized comparative effectiveness trial. Anesthesiology 2012;
117:717–725.
jury is still out as to the utility of processed EEG 14. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral
monitors, like the widely used BIS. Current research index for improving anesthetic delivery and postoperative recovery (review).
Cochrane Database Syst Rev 2014; CD003843.
suggests that processed EEG monitors may be most 15. American Society of Extracorporeal Technology Standards and Guidelines for
useful in specific patient populations, such as TIVAs Perfusion Practice. 2013. http://www.amsect.org/page/standards-and-
guidelines-1117 [Accessed 4 July 2016].
and in patients with hemodynamic compromise 16. Lindholm M, Traff S, Granath F, et al. Mortality within 2 years after surgery in
that requires the clinician to minimize the concen- relation to low intraoperative bispectral index values and preexisting malignant
disease. Anesth Analg 2009; 108:509–512.
tration of the vaporized agents. Alternatively, 17. Kertai MD, Pal N, Palanca BJA, et al. Association of perioperative risk factors
measuring ETAC and maintaining it greater than and cumulative duration of low bispectral index with intermediate-term mor-
tality after cardiac surgery in the B-Unaware trial. Anesthesiology 2010;
0.7 age-adjusted MAC can prevent awareness while 112:1116–1127.
being most cost-conscious. Lastly, looking to the 18. Kertai MD, Palanca BJA, Pal N, et al. Bispectral index monitoring, duration of
the bispectral index below 45, patient risk factors, and intermediate-term
unprocessed EEG is an area in which further research mortality after noncardiac surgery in the B-Unaware trial. Anesthesiology
is needed, as it may provide another alternative to 2011; 114:545–556.
19. Sessler DI, Sigl JC, Kelley SD, et al. Hospital stay and mortality are increased
monitoring depth of anesthesia and may prove to in patients having a ‘‘triple low’’ of low blood pressure, low bispectral index,
have a benefit on postoperative outcomes. and low minimum alveolar concentration of volatile anesthesia. Anesthesiol-
ogy 2012; 116:1195–1203.
20. Willingham MD, Karren E, Shanks AM, et al. Concurrence of intraoperative
Acknowledgements && hypotension, low minimum alveolar concentration, and low bispectral index
is associated with postoperative death. Anesthesiology 2015; 123:775–
None. 785.
This retrospective study demonstrated that the likelihood of 30-day and 90-day
mortality was increased approximately 10% for every 15 cumulative minutes in the
Financial support and sponsorship triple low state.
The authors did not receive any financial support for this 21. Willingham M, Abdallah AB, Gradwohl S, et al. Association between intrao-
perative electroencephalographic suppression and postoperative mortality.
article. Br J Anesth 2014; 113:1001–1008.

0952-7907 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-anesthesiology.com 715

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Technology, education and safety

22. Paventi S, Santevecchi A, Metta E, et al. Bispectral index 28. Soehle M, Dittmann A, Ellerkmann RK, et al. Intraoperative burst suppression
monitoring in sevoflurane and remifentanil anesthesia: analysis of drug && is associated with postoperative delirium following cardiac surgery: a pro-
management and immediate recovery. Minerva Anestesiol 2001; 67:435– spective, observational study. BMC Anesthesiol 2015; 15:61.
439. This study demonstrated that intraoperative assessment of the burst suppression
23. Rinehardt EK, Sivarajan M. Costs and wastes in anesthesia care. Curr Opin ratio may identify patients at-risk of postoperative delirium; however, it is still
Anesthesiol 2012; 25:221–225. unknown if the relationship is causal.
24. Jones KA, LaFerriere KA. Intravenous anesthesia with bispectral index mon- 29. Renna M, Handy J, Shah A. Low baseline bispectral index of the electroence-
itoring vs inhalational anesthesia for rhytidoplasty: a randomized clinical trial. phalogram in patients with dementia. Anesth Analg 2003; 96:1380–1385.
JAMA Facial Plast Surg 2015; 17:239–244. 30. Bennett C, Voss LJ, Barnard JPM, Sleigh JW. Practical use of the raw
25. Klopman MA, Sebel PS. Cost-effectiveness of bispectral index monitoring. electroencephalogram waveform during general anesthesia: the art and
Curr Opin Anesthesiol 2011; 24:177–181. science. Anesth Analg 2009; 109:539–550.
26. Brown EN, Lydic R, Schiff ND. General anesthesia, sleep and coma. N Engl J 31. Kertai MD, Whitlock EL, Avidan MS. Brain monitoring with electroencephalo-
Med 2010; 363:2638–2650. graphy and the electroencephalogram-derived bispectral index during cardiac
27. Fritz BA, Kalarickal PL, Maybrier HR, et al. Intraoperative electroencephalo- surgery. Anesth Analg 2012; 114:533–546.
gram suppression predicts postoperative delirium. Anesth Analg 2016; 32. Dahaba AA. Different conditions that could result in the bispectral index
122:234–242. indicating an incorrect hypnotic state. Anesth Analg 2005; 101:765–773.

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